By Elaine Christie, Author


Community health workers (CHWs) are lay health advocates who help to mitigate health disparities while building trusted patient–provider relationships. Decisions about how to best use community health workers depend on:

• needs of patients and care teams;

• clinical workflows and financial viability;

• addressing practice burdens while facilitating performance and cost-savings.

How can healthcare entities give patients necessary services that would prevent rehospitalization? Community health workers (CHWs) have the potential to enhance primary care access and benefit patients — but remain a largely untapped resource.

According to the American Public Health Association (APHA), there are seven key roles among CHWs:1

• bridging and providing cultural mediation between communities and health and social service systems;

• providing culturally appropriate health education and information;

• ensuring people obtain services they need;

• providing informal counseling and social support;

• advocating for individual and community needs;

• providing direct services, such as basic first aid and health screening tests;

• building individual and community capacity.

Community health workers, according to the APHA, are liaisons who help mitigate health disparities, increase access to care, improve quality of care, and lower healthcare costs. CHWs are nonclinical, nonmedical advisors and patient educators, also sometimes called lay health educators. They have a similar focus to patient navigators (PNs), who address health disparities across many chronic diseases.

Decisions about how to best use these workers depend on needs of patients and care teams, clinical workflows, financial viability, and addressing practice burdens while facilitating performance and cost savings.

A recent study in the Annals of Family Medicine2 says increasing the presence of CHWs also requires training and clinical integration necessary to build this new workforce, including certification, health information technology, and clinical oversight.

One of the study’s lead authors, Andrea Hartzler, PhD, of the Department of Biomedical Informatics and Medical Education at the University of Washington in Seattle, characterizes CHW roles and functions in primary care through 12 functions:

• care coordination;

• health coaching;

• social support;

• health assessment;

• resource linking;

• case management;

• medication management;

• remote care;

• follow-up;

• administration;

• health education;

• literacy support.

It’s an “interesting idea” for RN case managers to work alongside CHWs, Hartzler says. She points to a different study3 that took a similar approach.

“The goal was for a CHW to meet with high-risk hospitalized patients at discharge, then follow up with them via weekly phone calls post-discharge to identify and address barriers through community-based services and support for transition tasks. The CHW coordinated directly with nursing and front desk staff as patients returned to primary care,” she explains.

Due to poor protocol completion rates, she says, the study showed no statistically significant improvement over usual care. However, post-hoc interviews with the CHWs revealed a number of addressable barriers, including inadequate information and communication systems.

For instance, CHWs often lacked information on patients’ discharge timing, and thus missed 40% of discharge appointments, she notes. The missed opportunities to establish personal connections may have affected subsequent follow-ups.3

Hartzler says CHWs in that study also lacked logistical tools for tracking and monitoring follow-up when it did occur. Some system-level strategies to combat this and to better support CHWs include:

• using contact management tools;

• implementing appointment notifications;

• coordinating with nursing staff;

• providing additional training and support for CHWs.

One important role of the RN case manager would be to coordinate with the CHW to review patient information such as symptoms, concerns, and barriers to care, and provide the CHW with up-to-date logistical information on follow-up appointment schedules.

“Building empathy is important for building trusted patient–provider relationships, and CHWs can certainly facilitate information sharing and connection to that end,” Hartzler says.

In addition, regular contact to coordinate case management for individual patients may be needed to ensure the CHW shares concerns that require nurse intervention.

“One model for how that meeting could work is a routine huddle, perhaps weekly or daily, to monitor patient status during the discharge and post-discharge period as patients transition from hospital to primary care — approximately two to four weeks,” Hartzler says.

Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts, points to the proposed rule for discharge planning for ambulatory surgery patients, EDs, and all other outpatient procedures. “Because someone has an outpatient procedure, it doesn’t mean they don’t need follow-up,” she says.

“CMS has proposed that hospitals may have to assess all patients for continuing care services, not just inpatients, and that would be a big shift. I think it’s the right thing to do,” adds Cesta. “As more patients are treated in outpatient settings, they may need continuing care after ambulatory surgery or other invasive outpatient procedures. We don’t want these patients to have a poor recovery at home. In addition, these patients are at risk for returns to emergency departments or readmissions.”

Examples of Common Functions

Community health workers' roles vary, but core functions cluster into the following areas:

• Clinical services. This role focuses on health assessment and remote care more than other clusters. Examples include assessment of vital signs, lifestyle, health knowledge, psychosocial factors, and care through routine exams aided by remote communication with physicians. These services provide for patient dialogue, helping care teams understand patients’ health, backgrounds, and preferences.

One example would be a community health aid who provides clinical services in remote Alaskan villages using scripted questions and directed exams for common health problems.

• Community resource connections. These connections link patients with community-based services, such as referrals for transportation or food assistance. Ongoing social support and follow-up phone calls are common, yet remote care, education, and literacy support are less common.

Example: “Promotoras” who screen patients for depression by interviewing them about contextual factors (e.g., unemployment) and help resolve those barriers with community referrals (e.g., vocational training).

• Health education and coaching. Health coaching generally involves motivational interviewing and action planning to help patients achieve health goals.

Example: Peer health coaches who counsel, teach, and support self-management.

Guidance on Community Support

There’s a growing demand in the United States for transition-of-care navigators and more CHWs due to increased healthcare spending, regulatory demands and penalties, and patients with complex conditions who require high levels of services and account for a high percentage of costs.

“Many struggle with multiple illnesses combined with social issues such as mental health and substance abuse, extreme medical frailty, and social needs. It is very difficult for these patients to navigate the healthcare system,” says Terri Marshall, RN, MS, CCM, senior managing consultant at Berkeley Research Group.

There is a need for healthcare systems and ambulatory providers to focus on high-risk patients, such as those who are in the early stages of chronic diseases, and to provide education and understanding of disease processes.

“Both the acute care and outpatient providers work collaboratively to manage and assist the patients in every aspect of their care. Starting with handoff from acute care to ambulatory care, this is critical in ensuring patient safety and quality of care,” says Marshall.

Some of the key duties for community health workers include the following:

• helping the patient and family understand the importance of self-care and being able to advocate what they want from the healthcare team;

• working collaboratively in the acute care setting with the patient and family, providing education regarding the disease process and building the relationship to be a resource and support contact;

• developing an individual care plan that includes a call at 24 hours post-discharge to verify the patient understands the discharge instructions, follow up on any barriers to care (e.g., lack of transportation), and ensure a follow-up office visit is scheduled and any prescriptions are filled;

• making follow-up calls at 30-45 days post-discharge to screen for symptoms that suggest a worsening condition and knowing what to do in case of a problem.

Top Risk Factors

With ever-evolving models of care, the collaborative case management model can better serve high-risk patients. Community health managers can work to minimize some of the top risk factors affecting outcomes, according to Marshall. These risk factors include:

• Poor handoff from acute to ambulatory providers.

• Poor health literacy. Make sure there is a caregiver who understands the plan of care and can assist the patient. “Provide low literacy instructions and educational materials to facilitate patient understanding. Reduce the complexity of self-care instructions provided to patients,” says Marshall. (For more on health literacy, see related article in this issue.)

• Language barriers. Limited English proficiency is associated with lower rates of outpatient follow-up, use of preventive services, medication adherence, understanding diagnoses, and other factors, she explains.

• Cultural beliefs and customs. Unique personal customs may influence patients’ health behaviors, perceptions of care, and interpretation of medical information or advice, explains Marshall.

• Lack of support. Absence of family or caregivers may lead to social isolation. To prevent that, community health workers can make follow-up phone calls at 72 hours, verify appointments with a primary care provider, and arrange for home care services.

• Prior hospitalization. The collaborative care team must understand the reasons for hospitalization and whether it could have been prevented.

• Physical limitations. Engage family/caregivers to assist with post-discharge needs. Marshall recommends that community health workers follow up with a phone call at 72 hours to assess any care needs and adherence to the discharge plan.

• Polypharmacy. Patients may have difficulty understanding all of the prescribed medication instructions, or may need medication reconciliation to ensure they are not taking old or contraindicated prescriptions.

• Psychological issues. Positive depression screening and history of depression diagnosis also are risk factors.

Promoting Collaborative Care

Another issue is making sure team members are working toward the same goals. Everyone on the team must understand their shared purpose on both the community side and within hospital settings, Marshall stresses.

“It comes down to education, communication, and collaboration,” she says.

Develop a care transition work group to include home healthcare agencies, skilled nursing facilities, long-term acute care hospitals, and rehabilitation facilities, explains Marshall.

“Standardize education tools so that the hospital, physician, home health agency, and skilled nursing homes are all using the same language and documents to educate and instruct the patient,” she adds. “Consider sharing access to medical records to improve clinical data-sharing.”

Cesta adds that case managers often don’t include the family during discharge planning educational episodes.

“When people are sedated or tired, a family member should also be present. We don’t always take the time to focus in on the family or family caregivers,” she says.

Indeed, poor communication among healthcare providers and the lack of shared information about patients are common causes of undertreatment, suboptimal therapy, adverse drug events, and hospital admissions or readmissions.

Looking Toward the Future

Going forward, what should healthcare teams focus on?

“In a nutshell, we have bundled payments and other payment modalities that require that we consider the patient’s needs at all points across the continuum of care,” says Cesta. “Most hospitals need to create case management departments that incorporate case management in the community setting with inpatient case management staff, thereby creating one case management department. We propose having a senior leader who has responsibility for the division of acute care case management and community-based case management.”

In a perfect world the two teams would meet monthly, with hospital case managers seeing what happens to certain high-risk patients out in the community setting, and for the community health workers to see what happens when they come back to the hospital.

“What failed on the community side, perhaps? It’s kind of like ‘walk a mile in someone else’s shoes’ because there’s typically not a good understanding of what happens to patients after they leave the hospital and risk factors that can affect outcomes,” she adds.


1. American Public Health Association. Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities. Nov. 10, 2009. Available at:

2. Hartzler A, Tuzzio L, Hsu C, Wagner EH. Roles and Functions of Community Health Workers in Primary Care. Ann Fam Med May/June 2018 16:240-245; doi:10.1370/afm.2208.

3. Burns ME, Galbraith A, Ross-Degnan D, Balaban RB. Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions. Int J Qual Health Care 2014 Aug;26(4):358-65. doi: 10.1093/intqhc/mzu046.